直肠肛管恶性黑色素瘤的外科治疗及预后

目的探讨直肠肛管恶性黑色素瘤的外科治疗及局部复发、预后的影响因素。方法回顾性分析50例直肠肛管恶性黑色素瘤患者的临床病理资料,并对预后进行单因素及多因素分析。结果本组47例患者行肿瘤切除术,其中31例行腹会阴联合根治术,16例行肿瘤局部切除术;术后局部复发率分别为16.1%（5/31）和68.8%（11/16）。χ^2检验显示,手术方式与局部复发相关（P=0.001）。47例患者5年生存率18.2%,单因素分析显示,病灶单发（P=0.0458）和肿瘤侵犯深度（P=0.0053）与预后相关。多因素分析显示,肿瘤侵犯深度（P=0.010）是影响预后最主要因素。结论直肠肛管恶性黑色素瘤预后差,影响预后最主要的因素是肿瘤侵犯深度,腹会阴联合根治术后复发率低。     

胃肠道恶性黑色素瘤70例临床分析

目的 探讨胃肠道恶性黑色素瘤的诊治方法,提高诊治水平.方法 总结1965年7月至2007年6月收治的70例胃肠道恶性黑色素瘤患者的临床资料.结果 70例患者中男性27例,女性43例,年龄25～75岁,中位年龄53岁,其中50例发生于直肠,10例发生于肛管,10例发生于食管.1、3、5年生存率分别为48.3%、14.6%、6.5%,中位生存时间为379 d.63例接受手术治疗,单纯手术的25例患者和术后辅助化疗、放疗、生物治疗等综合治疗的38例患者的总生存率无统计学差异,Ⅲ期患者综合治疗组较单纯手术组生存率显著升高.风险因素分析提示病变深度为胃肠道恶性黑色素瘤的危险因素.结论 手术加综合治疗能提高Ⅲ期胃肠道恶性黑色素瘤的生存率;病变深度是影响生存率的风险因素.     

直肠肛管恶性黑色素瘤的诊治

目的 探讨直肠肛管恶性黑色素瘤的临床表现、诊断、治疗及预后。方法 回顾性分析了1981－1996年我科诊治的直肠肛管恶性黑色素瘤6例，并进行随访。结果 6例患者肿块位于齿状线附近，肉眼观为紫黑色或褐色，均行手术治疗，其中2例行Mile′s术，2例行后盆腔清扫术，1例行经肛门肿块局部扩大切除术，1例行剖腹探查术，所有患者手术时均已有淋巴结或肝脏转移。6例患者于确诊后5－23个月死亡，平均存活14．7个月。结论 直肠肛管恶性黑色素瘤恶性度极高，死亡率高，较早发生淋巴和血行转移，宜采用根治手术辅以化疗及生物治疗的综合性治疗。     

手术方式对肛管直肠恶性黑色素瘤预后的影响

目的比较经腹直肠肛门切除术(abdominoperinealresection,APR)与经肛局部扩大切除术(widelocalexcision,WLE)对肛管直肠恶性黑色素瘤(anorectalmalignantmelanoma,AMM)预后的影响。方法回顾分析1980年至2002年经手术治疗的42例AMM患者的临床资料。结果局部复发WLE术后62%、APR术后61%;平均生存时间WLE术后24.3个月,APR术后20.0个月;两组生存期比较,χ2=0.728,P>0.05,差异无显著性意义。结论AMM患者的预后与外科手术方式无关,应根据患者的综合因素来选择手术方式。     

肛管直肠恶性黑色素瘤的诊治

目的 探讨肛管直肠恶性黑色素瘤的临床特点，诊断，治疗及预后。方法 对近21年来经手术及病理证实的11例肛管直肠恶性黑色素瘤临床特征，治疗方法及预后进行回顾性分析。结果 11例中7例有不同程度的便，肛周疼痛等肛门症状，术前误诊7例。全组均行腹会阴联合切除术，术后平均生存18个月，最长存活39个月。结论 肛管直肠恶性黑色素瘤恶性程度极高，死亡率高，较早发生淋巴和血行转移，宜 采用根治手术，辅以化疗及生物治疗的综合性治疗。     

肛管直肠恶性黑色素瘤34例治疗与预后分析

目的探讨肛管直肠恶性黑色素瘤（ARMM）的预后影响因素。方法回顾性分析1993年3月至2011年11月问解放军总医院收治的34例肛管直肠恶性黑色素瘤患者的临床资料．分析临床病理因素与预后的关系。并采用Cox比例风险模型进行多因素预后分析。结果34例ARMM患者中,26例行腹会阴联合切除手术（APR）,8例行局部扩大切除术（wLE）;术后行辅助治疗者20例,其中化疗14例,放疗2例。中医中药治疗4例,免疫治疗16例。术后均接受随访,中位随访时间27个月。1、3和5年的总生存率分别为76.3％、39．6％和20．6％,1、3和5年的无病生存率分别为60．6％、30-8％和12．8％。APR和WLE术后局部复发率分别为0（0／26）和5／8,行和未行术后免疫治疗者局部复发率分别为0（0／16）和27．8％（5／18）,差异均有统计学意义（均P〈0．05）。单因素预后分析显示,肿瘤大体分型、浸润程度、淋巴结转移和临床分期与术后总体生存有关,淋巴结转移、术后免疫治疗和辅助治疗与术后无病生存有关（均P〈0．05）。多因素预后分析显示,肿瘤浸润程度和临床分期是术后总体生存的独立预后因素（均P〈0．05）,而术后无病生存的独立预后因素未获证实（均P〉0．05）。结论合理选择手术方式和术后免疫治疗是提高ARMM患者治疗效果的关键。     

肛管直肠恶性黑色素瘤

目的　总结肛管直肠恶性黑色素瘤的诊断与治疗经验。　方法　回顾性分析 10例肛管直肠恶性黑色素瘤的临床病例资料。　结果　出现症状至确诊时间平均 8( 2～ 12 )个月 ,首诊确诊 4例 ,误诊 6例。手术 9例 ,8例肿瘤直径 >3cm。其中 8例行腹会阴联合根治术 ,1例以直肠息肉、肛乳头肥大行局部切除 ,1例放弃手术仅行化疗 ,3月后死于肝、肺腹股沟等广泛转移。术后 8例行化疗 ,2例辅助放疗 ,化放疗联合应用 1例。术后 2年内死亡 5例 ,余 4例存活 ,存活最长者已超过 6年。　结论　肛管直肠恶性黑色素瘤恶性程度高 ,早期行腹会阴联合根治术是最优选择。长期生存有赖于早期治疗以及治疗方法的改进     

原发性肛管直肠恶性黑色素瘤病例1例并文献复习

目的:探讨原发性肛管直肠恶性黑色素瘤(PAMM)的临床及病理特征、诊断和治疗方法。方法:回顾性分析1例原发性肛管直肠恶性黑色素瘤患者的病历资料,结合国内外文献,总结PAMM的临床和病理特点、诊断和治疗方法。结果:该患者术前肠镜提示距肛缘4cm处肿块,肠镜下活检病理提示恶性黑色素瘤,行腹部会阴切除术,术后病理再次证实肛管直肠恶性黑色素瘤。术后患者顺利出院。结论:PAMM是非常罕见的恶性肿瘤,临床表现缺乏特异性,确诊需要病理诊断。预后差,手术切术是治疗原发性肛管直肠黑色素瘤的最佳方案。     

肛管直肠恶性黑色素瘤的诊断和治疗（附9例分析）

目的 探讨肛管直肠恶性黑色素瘤的临床特点。方法 回顾性分析1996～2003年我科收治的9例肛管直肠恶性黑色素瘤的临床特点、诊治方法和预后。结果 肛管直肠恶性黑色素瘤最常见的临床表现是便血(78％)。本组行腹会阴联合切除术5例，局部广泛切除术2例，随访发现7例均在术后2年内发生局部复发或远处转移。最长生存32个月，2例晚期患者存活不到3个月。结论 肛管直肠恶性黑色素瘤临床少见，容易误诊漏诊，外科手术是首选的治疗方法，但是无论Miles’术还是局部广泛切除术，术后生活质量和生存期均不理想，提高治疗水平的唯一途径是早期诊断和早期规范治疗。     

原发性肛管直肠恶性黑色素瘤29例诊治体会

目的了解肛管直肠恶性黑色素瘤的生物学特性和根治性外科手术在治疗该病中的临床意义。方法回顾性总结自１９６５年至１９９５年在我院接受治疗的肛管直肠恶性黑色素瘤患者２９例的临床和病理资料。结果本组女１９例,男１０例,平均年龄５０岁。２９例患者中,接受了根治性手术（Ｍｉｌｅｓ手术）２３例。术后复发１７例,复发率为７４％（１７／２３）,主要复发部位为远处转移。以性别,癌灶体积,色素产生,浸润深度和淋巴结转移为变量分析与预后的关系,仅淋巴结转移与术后复发的关系非常密切（Ｐ＜００５）。其余６例接受姑息性手术治疗。全组病例术后总５年生存率为２９％。根治性手术病例术后５年生存和无病生存率分别为３７％和２８％。未切除的６例全部死亡。中位生存期为１３５个月。结论肛管恶性直肠黑色素瘤是一种恶性程度极高的肿瘤。即使施行根治性外科手术治疗预后亦不佳。术中见到有淋巴结转移者预后更差。     

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目的　探讨门静脉区域化疗对原发性肝癌完全切除术后的复发和转移的预防效果。方法　 1997年10月至 2 0 0 0年 10月间 ,广州医学院附属第二医院对 4 2例原发肝癌手术切除后分别行肝动脉 (18例 )或门静脉(2 4例 )区域预防性化疗。结果　两组间的术后 1、3、5年总生存率差异无显著意义 (P >0 0 5 ) ,门静脉化疗组的1、3年无瘤生存率显著高于肝动脉化疗组 (P <0 0 5 )。结论　术后门静脉区域预防性化疗可预防和延缓肝癌切除术后的复发和转移。     

The role of abdominoperineal resection as surgical therapy for anorectal melanoma

OBJECTIVES: 1) Characterize changes in the surgical treatment of anorectal melanoma over time. 2) Determine if the extent of surgical resection is associated with outcome. 3) Identify prognostic factors correlating with survival. SUMMARY BACKGROUND DATA: Although early data suggested improved survival in patients undergoing abdominoperineal resection (APR) for primary anorectal melanoma, such an aggressive approach may be unwarranted as distant relapse rates are high. We have seen a trend toward less aggressive surgical treatment of the local disease over the past 20 years. METHODS: A retrospective review was performed of all patients with anorectal melanoma treated at our institution between 1984 and 2003. Extent of primary resection and pathologic factors were studied. RESULTS: Forty-six patients underwent a curative resection with a median follow-up of 29 months, and 5-year disease-specific survival (DSS) rate of 35%. While patient and tumor characteristics remained similar, there was a dramatic shift in surgical treatment toward less radical procedures. Prior to 1997, the majority of patients (15 of 21, 71%) underwent APR. After 1997, the majority of patients (21 of 25, 84%) underwent local excision (LE) (P < 0.0001). Local recurrence was noted in 11 of 46 (24%) patients: 4 of 19 (21%) who underwent APR and 7 of 27 (26%) who underwent LE (P = not significant). Five-year DSS was similar: 34% following APR and 35% following LE. Tumor perineural invasion (PNI) was the only factor identified as an independent predictor of worse outcome (P = 0.01). CONCLUSION: The extent of surgical treatment is not associated with outcome in primary anorectal melanoma. Therefore, LE of the primary tumor is recommended when technically feasible. The presence of PNI is an important prognostic factor and should be considered in future clinical trials.     

肛管直肠恶性黑色素瘤的外科治疗

目的 探讨肛管直肠恶性黑色素瘤的临床特征、诊断及治疗经验.方法 总结中国医科大学附属第四医院及附属第一医院33例肛管直肠恶性黑色素瘤患者的临床资料.依据手术方式分组,应用Fisher确切概率法,Kaplan-Meier方法和Log-rank检验进行统计学分析.结果 肛管直肠恶性黑色素瘤以女性多见,发病年龄22～77(54.5 ±7.6)岁.便血、肛门疼痛为最常见的临床表现.首次就诊误诊率为67%(22/33).肿瘤平均直径(3.5 ± 1.7) cm,31例(94%,31/33)的肿瘤距肛缘不足5 cm.术后平均生存期(14.0 ± 6.5)个月,1、3、5年总生存率分别为48%、22%、10%.腹会阴联合切除组与局部切除组术后局部复发率比较,差异有统计学意义(P=0.049),3年特异性生存率差异无统计学意义(x2=0.268,P=0.582).结论 肛管直肠恶性黑色素瘤极易误诊,扩大切除并不能有效延长患者的生存期.

Abstract：

Objective To evaluate clinical features, diagnosis and treatment of anorectal malignant melanoma (ARMM).Methods The clinical data of 15 patients of ARMM in our hospital and 18 patients in the First Affiliated Hospital of China Medical University from 1990 to 2010 were reviewed.Twenty-five patients underwent curative surgical resection, 14 patients underwent abdominoperineal excision of the rectum (APR), and 11 patients underwent local excision (LE).Survival analysis was carried out.Fisher's exact test and Log-rank test was used to compare the effects of these two different surgical procedures.Results ARMM had a female predominance, the mean age was 22 -77(54.5 ± 7.6) years.The major clinical signs included hematochezia, anus pain.The misdiagnosis rate was 67% (22/33).The average tumor size was (3.5 ±1.7) cm.Thirty-one petients(94% ,31/33) had ARMM within 5 cm from anus margin.Mean survival time was (14.0 ± 6.5)months.The overall 1-,3-,and 5-year survival rates were 48% ,22% , and 10% , respectively.Local recurrence after curative LE was higher than APR (LE,64% vs APR, 21% , P = 0.049) , The overall 3-year disease-specific survival rates after curative LE was not significantly different from that of APR (LE, 28% vs APR ,31%, x2 = 0.268, P = 0.582).Conclusions Anorectal malignant melanoma has a high rate of misdiagnosis.Radical resection could not prolong the survival time significantly in anorectal malignent melanoma patients.     

手术方式影响肛管直肠恶性黑色素瘤的预后

目的:比较经腹直肠肛门切除术(AbdominoperinealResection,APR)与经肛门局部切除术(LocalExcision,LE)对肛管直肠恶性黑色素瘤(anorectalmalignantmelanoma,AMM)预后的影响。方法:回顾分析1994年至2004年我院经手术治疗的8例AMM患者和1994年至2004年12月CNKI全文数据库以个案报道并有随访资料的文献共44篇107例的临床资料。根据手术方式分组应用寿命表法和KaplanMeier方法(SPSS10.0forwindows)进行统计分析。结果:根治性手术治疗AMM的1、2、3、5年生存率分别为55.26%、37.76%、31.21%、20.34%,中位生存时间为21.24个月;其中LE术后的1、2、3、5年生存率分别为48.39%、27.60%、27.60%、9.20%,中位生存时间为11.75个月;APR手术后的1、2、3、5年生存率分别为62.26%、41.62%、32.87%、25.13%,中位生存时间25.01个月。KaplanMeier法比较APR术与LE术的生存率有显著差异(P<0.05)。结论:AMM患者的预后与外科手术方式有密切关系,APR手术预后好于LE手术,提示首次治疗手术方式选择较重要,应根据患者的综合因素来选择手术方式。     

Surgical therapy for anorectal melanoma

BACKGROUND: Anorectal melanoma is a rare but highly lethal malignancy. Historically, radical resection was considered the "gold standard" for treatment of potentially curable anorectal melanoma. The dismal prognosis of this disease has prompted us to recommend wide local excision as the initial therapeutic approach. The purpose of this study was to review our results in patients who underwent wide local excision or radical surgery (abdominoperineal resection [APR]) for localized anorectal melanoma. STUDY DESIGN: We reviewed the charts of all patients referred for resection of anorectal melanoma between 1988 and 2002. Endpoints included overall survival, disease-free survival, and local, regional, or systemic recurrence. RESULTS: Fifteen patients underwent curative-intent surgery; four underwent APR and 11 underwent wide local excision. Eight patients (53%) are alive; 7 (47%) are disease-free (followup 6 months to 13 years). Of 12 patients who have been followed for more than 2 years, 4 are alive (33%) and 3 are disease-free (25%). Seven patients have been followed for more than 5 years and two are alive and disease-free (29%). All of the longterm survivors underwent local excision as the initial operation. There were no differences in local recurrence, systemic recurrence, disease-free survival, or overall survival between the APR group and the local excision group. Local recurrence occurred in 50% of the APR group and 18% of the local excision group; regional recurrence occurred in 25% versus 27%. Distant metastases were common (75% versus 36%). CONCLUSION: In patients who have undergone resection with curative intent for anorectal melanoma, most recurrences occur systemically regardless of the initial surgical procedure. Local resection does not increase the risk of local or regional recurrence. APR offers no survival advantage over local excision. We advocate wide local excision as primary therapy for anorectal melanoma when technically feasible.     

Primary ano-rectal melanoma

Primary malignant anorectal melanoma is an uncommon disease that accounts for 1% of anorectal malignancies. Its virulent malignancy is associated with a poor prognosis and with difficult diagnostic and therapeutic problems. The operative management of these patients is controversial. Clinicopathologic features and surgical treatment of 6 patients with primary anorectal melanoma were studied retrospectively. There was a male preponderance (2:1) with a mean age of 62 years (range: 34-74). The site of origin of the melanoma was rectal in one patient and in the anorectal junction in five patients. Atypical intramucosal melanocyte proliferation was associated with rectal melanoma. The maximum tumor size from 2 to 5.5 cm. Common initial symptoms were rectal bleeding and/or tenesmus. CT was useful for tumor staging. Two patients had distant metastases at initial presentation. Four patients underwent "curative" treatments by abdominoperineal resection and 2 by local excision. The survival for the group as a whole was poor (mean: 12.6 months; range: 7-30 months). Surgery is the primary option. The prognosis, however, is poor, since metastatic disease is commonly established at presentation. Atypical intramucosal melanocyte proliferation may be a marker in association with tumor sited in the rectum.     

Primary amelanotic anorectal melanoma--a case report

BACKGROUND: The amelanotic melanoma of the rectal mucosa is very rare with an unfavourable prognosis. The surgical approach is still discussed controversially. Therefore transrectal ultrasound is of major importance in the preoperative staging and postoperative follow-up especially in diagnosis of local recurrence by using the ultrasound-guided, transrectal aspiration. METHODS: In literature 5 cases of amelanotic malignant melanoma were reported. The overall survival time is 10 months after diagnosis. All patients were female. RESULTS: We report about a 55-year-old female patient with an amelanotic melanoma of rectal mucosa. 7 months after a wide local excision of the tumour and interferon therapy in case of the absence of pararectal, inguinal metastases and other metastases the patient developed pararectal metastasis. An abdominoperineal resection and resection of inguinal lymph nodes was performed. Two months later paraaortal lymph nodes were detected. We started chemotherapy with Dacarbazin and with regard of the tumour progress the chemotherapy was changed to Vindesin 25 months after first operation supported by a radiotherapy with 40 Gray. The patient died 36 months after diagnosis. CONCLUSION: The prognosis of primary malignant anorectal melanoma is poor, irrespective of surgical treatment. Wide local resection is the first choice for primary anorectal melanoma. Abdominoperineal resection should be reserved for cases were complete tumour resection is impossible. Chemotherapy, radiotherapy and immunotherapy should be considered in the treatment of anorectal melanoma to influence the overall survival.     

结直肠癌性梗阻的外科治疗: 附108例报告

目的　探讨结直肠癌性梗阻的治疗原则。方法　回顾性分析 10年间我院收治的 10 8例结肠梗阻患者的临床资料和治疗方法 :右半结肠癌 3 0例中 2 8例行一期切除吻合 ,1例行姑息性手术 ,1例未手术。左半结肠和直肠癌 78例中行一期切除 ( 5 6例 ) (Ⅰ期或Ⅱ期吻合分别 3 2 ,2 4例 )或二期切除11例 ,6例行姑息性手术 ,5例未手术。结果　伴结肠梗阻的结直肠癌多见于Duke′sC和D期 ( 5 9例 )的中、低分化腺癌 ( 65例 )。手术并发症发生率为 2 7.3 % ( 2 6例 46例次 ) ,以感染性并发症为主 ( 3 5 /46) ,吻合口漏 4例。围手术期死亡率为 7.8%。手术治疗患者的 5年生存率为 2 8.4% ,未手术者 5年生存率为 0 % (P <0 .0 1)。肿瘤I期 ,II期切除 5年生存率分别为 3 3 .3 % ,9.0 % (P <0 .0 5 )。肿瘤一期切除后行一期 ,二期吻合手术的 5年生存率无显著性差异 (P >0 .0 5 )。结论　对伴结肠梗阻的结直肠癌 ,手术应及时并遵循个体化原则 ,创造条件 ,要力争一期手术切除肿瘤 ,解除梗阻 ,但切除后行I期或II期吻合对预后无影响。     

肛管直肠恶性黑色素瘤91例外科治疗及预后分析

目的 探索肛管直肠恶性黑色素瘤（ARMM）的外科治疗方式及影响病人总生存的预后因素。方法 回顾分析2003年1月至2018年1月北京大学肿瘤医院胃肠肿瘤中心诊断为ARMM并接受手术治疗的91例病人的临床病理资料。比较不同临床病理因素、手术方式［扩大的局部切除（WLE）与腹会阴联合切除（APR）］对病人总生存的影响。结果 在91例ARMM病人中,男性35例（38.5%）, 女性56例（61.5%）,男女比例为1.0∶1.6。接受WLE 12例（13.2%）,APR 79例（86.8%）。;术前存在远处转移19例（20.9%）,无远处转移72例（79.1%）。病人1、3和5年存活率分别为74%、23%和9%,中位生存期为18.7个月。单因素分析示术前远处转移、肿瘤直径＞2 cm、肿瘤侵犯深度＞2 mm和淋巴结转移为总生存的影响因素;多因素分析显示术前存在同时性远处转移和淋巴结转移为总生存的独立预后因素。12例接受WLE病人中位生存期为21个月,79例接受APR病人中位生存期为21个月,接受WLE和接受APR病人两组生存期差异无统计学意义（P=0.94）。结论 术前存在远处转移、淋巴结转移是ARMM病人总生存的独立预后因素。APR与WLE相比,并不能带来生存的获益。